When Is Peripheral Arterial Disease (PAD) The Cause?
Anthony J. Avino, M.D., F.A.C.S.
There are many causes of leg pain ranging from arthritis to bulging discs in your lower spine to blockages in the arteries of your legs (peripheral arterial disease or P.A.D.). Other causes include neuropathy, fibromyalgia, venous insufficiency or swelling and an assortment of muscular-skeletal conditions (ailments affecting muscles, joints, bones, tendons etc.). While all of these conditions can cause significant discomfort, a diagnosis of peripheral arterial disease has the greatest implications for your health. A good understanding of when leg pain is caused by P.A.D. is very important not only because this will affect treatment options but also because P.A.D is associated with significantly increased risks of heart attack, stroke and death.
WHAT IS PERIPHERAL ARTERIAL DISEASE?
P.A.D. is a very common condition that affects an estimated eight million Americans. P.A.D. occurs most often in the arteries of the legs but can also affect the arteries that carry blood to the brain, the arms, the kidneys and other vital organs. When blockages affect the arteries to the heart, this is called coronary artery disease. The buildup of plaque in arteries causes the arteries to harden and narrow and this significantly reduces blood flow. This serious condition is called atherosclerosis and often referred to as "hardening of the arteries" or "poor circulation."
WHAT ARE THE SYMPTOMS OF P.A.D. AS OPPOSED TO THE MANY OTHER CAUSES OF LEG PAIN?
This distinction is very important since most leg pain is not caused by circulation problems. Night cramps and leg pain while you are sitting, lying or standing is
rarely caused by PAD. Pain Anthony J. Avino, M.D., F.A.C.S. in your joints, feet or back while walking is most frequently related to one of many muscular-skeletal disorders.
Symptoms of P.A.D. are usually very specific. The most common signs include calf or thigh or buttock muscle pain that occurs while walking (not night cramps) and is relieved with only a couple minutes of rest. This is called claudication and occurs when blockages prevent the additional flow of blood and oxygen needed by the muscles for the extra work of walking.
Your physician can review your history and risk factors and examine the pulses in your feet and legs. If your pulses are normal, you do not have P.A.D. If your pulses are weak or absent, you may well have P.A.D. and require further diagnostic studies.
WHY IS PAD. CONSIDERED SUCH A SERIOUS CONDITION?
People with hardening of the arteries in the legs also frequently have hardening of the arteries to the heart and brain. This is why P.A.D. is considered a significant marker for increased risk of having a heart attack or stroke. When the blockages in the legs are mild or moderate, treatment for the leg blockages may not be necessary but it is very impor tant to reduce the risks of heart attack, stroke and disease progression. More serious blockages cause further reductions in blood flow which causes pain during walking and can lead to disabling symptoms that seriously affect quality of life. As further reductions in blood flow occur, some people will develop non-healing ulcers, gangrene and may even risk possible amputation.
WHAT ARE THE RISK FACTORS FOR P.A.D.?
- Smoking is by far the number one greatest risk factor. As many as one out of two people with PAD who continue to smoke will have a heart attack or stroke or die within 5 years.
- Diabetes, especially if poorly controlled or present for many years
- High blood pressure and cholesterol levels
- History of heart attack, stroke or other vascular disease
- Age greater than 50 and family history of vascular disease
WHAT DO I NEED TO DO IF I AM DIAGNOSED WITH PAD?
Since PAD is a marker for other blockages to the arteries of your heart and brain, you should take several life saving steps to help prevent heart attack, stroke, amputation and death from progression ol vascular disease:
- Get help quitting smoking. Current smoking cessation medications are far more effective than in the past and you can significantly lower your future risks by quitting now. The most recent and effective smoking cessation medication is Chantix® which reduces wirhdrawal symptoms, increases the will to quit (reduces the sense of rush or calmness when lighting up) and has few side effects.
- Lower your bad (LDL) cholesterol and raise your good (HDL) cholesterol through diet and exercise. There is overwhelming evidence that people at risk for vascular disease have a tremendous benefit from cholesterol lowering medications called statins.
- Lower your blood pressure to less than 130/80mmHg and your blood glucose to reach an A1C level of less than 7 if you are diabetic.
- Take anti-platelet medication such as coated baby aspirin or Plavix® unless you are allergic.
- Commit to life style changes including regular exercise and a healthy eating plan. Most people cannot accomplish this on their own and need help such as organized, aerobic exercise classes and proven weight loss programs such as Weight Watchers. Don't waste your money on short term fixes advertised on television and radio.
WHAT TREATMENTS ARE AVAILABLE FOR BLOCKAGES IN LEG ARTERIES?
- Unfortunately, there are no medications that make the blockages dissolve. However, there are two FDA-approved medications to improve walking distance when it is limited by P.A.D. The oldest is pentoxyfyiine (Trental®) which has been shown to be no better than placebo (sugar pills). Cilostazol (Pletal®) has been available for over ten years and affords improved walking distance in approximately half of patients with P.A.D.
- Angioplasty and stenting are non-surgical options of opening blockages similar to treating blockages in heart arteries. A long, thin plastic tube called a catheter is placed inside your artery through a tiny puncture in the groin and guided to the area of the blockages using x-ray. A very small balloon or a stent (small, flexible wire mesh tube) is placed on the tip of the catheter to open the narrowed artery. These procedures are typically successful and performed in an outpatient setting. A vascular surgeon is best trained to determine if this is a good option for you or if you are better served with open surgery.
- Surgical bypass procedures utilize one of your own veins or a man-made conduit (long, thin tube) that is sewn to the artery above and below the area of blockage to re-route blood. This surgery typically has a good success rate but requires admission to the hospital for several days and a longer recovery than angioplasty and stenting.
Dr. Avino is a board-certified vascular surgeon who specializes in minimally-invasive vascular procedures at Savannah Vascular Institute and can be reached at 912-350-VEIN or This e-mail address is being protected from spambots, you need JavaScript enabled to view it .
